The Gift Relationship

From Human Blood to Social Policy

Titmuss, Richard, Richard M Titmuss

• Publisher: Policy Press
• Year: 2018
• Print ISBN: 9781447349570
• eBook ISBN: 9781447349617
• Edition: 1
• Topic: Politics & International Relations
• Subtopic: Health Policy
• Index: Politics & International Relations

Richard Titmuss (1907-1973) was a pioneer in the field of social administration (now social policy). In this reissued classic, listed by the New York Times as one of the 10 most important books of the year when it was first published in 1970, he compares blood donation in the US and UK, contrasting the British system of reliance on voluntary donors to the American one in which the blood supply is in the hands of for-profit enterprises, concluding that a system based on altruism is both safer and more economically efficient.

Titmuss's argument about how altruism binds societies together has proved a powerful tool in the analysis of welfare provision. His analysis is even more topical now in an age of ever changing health care policy and at a time when health and welfare systems are under sustained attack from many quarters.

1

Introduction: human blood and social policy

The starting-point of this book is human blood: the scientific, social, economic and ethical issues involved in its procurement, processing, distribution, use and benefit in Britain, the United States, the Soviet Union, South Africa and other countries. The study therefore examines beliefs, attitudes and values concerning blood and its possession, inheritance, use and loss in diverse societies, past and present, and draws on historical, religious and sociological materials. It investigates by a variety of research methods the characteristics of those who give, supply or sell blood, and analyses in comparative terms blood transfusion and donor systems and national statistics of supply, demand and distribution particularly in Britain and the United States. Criteria of social value, cost efficiency, biological efficacy, safety and purity are applied to public and private markets in blood and to voluntary and commercial systems of meeting steeply rising world demands from medicine for blood and blood products.

The study originated and grew over many years of introspection from a series of value questions formulated within the context of attempts to distinguish the ‘social’ from the ‘economic’ in public policies and in those institutions and services with declared ‘welfare’ goals. (An earlier attempt to define the territory of social policy together with the roles and functions of the social services was made by Richard M. Titmuss in Commitment to Welfare, particularly Chapter 1.) Could, however, such distinctions be drawn and the territory of social policy at least broadly defined without raising issues about the morality of society and of man’s regard or disregard for the needs of others? Why should men not contract out of the ‘social’ and act to their own immediate advantage? Why give to strangers? – a question provoking an even more fundamental moral issue: who is my stranger in the relatively affluent, acquisitive and divisive societies of the twentieth century? What are the connections then, if obligations are extended, between the reciprocals of giving and receiving and modern welfare systems?

To speculate in such ways from the standpoint of the individual about gift relationships led us inevitably into the area of economic theory. In particular, we were forced to ask ‘economic man’ questions about those institutions which are (or may be) redistributive in some form or other, and which during this century have come to be known as ‘social services’ or ‘social welfare’. Examining, as a case study, one such manifestation of social policy, we came to ask: is medical care analysed in its many component parts – such as blood transfusion services – a consumption good indistinguishable from other goods and services in the private economic market? What are the consequences, national and international, of treating human blood as a commercial commodity? If blood is morally sanctioned as something to be bought and sold, what ultimately is the justification for not promoting individualistic private markets in other component areas of medical care, and in education, social security, welfare services, child foster care, social work skills, the use of patients and clients for professional training, and other ‘social service’ institutions and processes?

Where are the lines to be drawn – can indeed any lines at all be pragmatically drawn – if human blood is to be legitimated as a consumption good? To search for an identity and sphere of concern for social policy would therefore be to search for the non-existent. All policy would become in the end economic policy and the only values that would count would be those that could be measured in terms of money and pursued in the dialectic of hedonism. Each individual would act egoistically for the good of all by selling his blood for what the market would pay. To abolish the moral choice of giving to strangers could lead to an ideology to end all ideologies.

As the questions grow, so does the book. It moves from the particular and microscopic – human blood – to the general and fundamental issues posed by philosophers for centuries. Essentially then, the study is about the role of altruism in modern society – hence its title. It attempts to fuse the politics of welfare and the morality of individual wills.

Men are not born to give; as newcomers, they face none of the dilemmas of altruism and self-love. How can they and how do they learn to give – and to give to unnamed strangers irrespective of race, religion or colour – not in circumstances of shared misery but in societies continually multiplying new desires and syndicalist private wants concerned with property, status and power?

We do not answer these great questions. Step by step, however, we found we were compelled to raise them in examining the extent to which specific instruments of public policy encourage or discourage, foster or destroy the individual expression of altruism and regard for the needs of others. Put in another way, we wanted to know whether these instruments or institutions positively created areas of moral conflict for society by providing and extending opportunities for altruism in opposition to the possessive egoism of the marketplace. If the opportunity to behave altruistically – to exercise a moral choice to give in non-monetary forms to strangers – is an essential human right, then this book is also about the definition of freedom. Should men be free to sell their blood? Or should this freedom be curtailed to allow them to give or not to give blood? And, if this freedom is to be paramount, do we not then have to regard social policy institutions as agents of altruistic opportunities and therefore as generators of moral conflict and not simply as utilitarian instruments of welfare?

In the course of inquiring and trespassing, by amateurish paths, into the territory of the political philosopher, the economist and the medical scientist, we came to study systems of medical care and to address somewhat metaphysical questions to its constituent parts. For obvious reasons, we could not examine all these parts in depth, sector by sector, and on a comparative cross-national basis; we therefore chose to investigate blood donor and transfusion services. We believe this sector to be one of the most sensitive universal social indicators which, within limits, is measureable, and one which tells us something about the quality of relationships and of human values prevailing in a society. It also happens to be a crucial medical resource factor; the future of surgical care and many forms of curative and preventive medicine are dependent on the supply of uncontaminated human blood and blood products. Yet, over large parts of the world today, blood for transfusion is scarcer than many other medical care facilities.

Though, in this book, we abstract for a time this particular sector from its medical care setting, for intensive study we need to remember that we cannot understand the part unless we also understand the whole. ‘Society has to be studied in the individual, and the individual in society; those who wish to separate politics from morals will never understand either.’ Rousseau’s thought may be applied to the individual as a potential blood donor and to the ‘society’ of medical care. We cannot understand in Britain the National Blood Transfusion Service without also understanding the National Health Service, its origins, development and values. Similarly, we cannot understand the blood donor or blood seller in the United States without understanding that country’s systems of medical care.

There are some who argue from theories of political and economic convergence that we are today approaching the end of the ideological debate; within Britain and other Western societies and considered also in comparative national terms. These propositions are, we believe, dominated by economic and material maximising values just as Marx offered, as an alternative to the capitalist market, a crude utilitarianism. This study, in one small sector of human affairs, disputes both the death of ideology and the philistine resurrection of economic man in social policy. It is therefore concerned with the values we accord to people for what they give to strangers; not for what they get out of society.

2

The transfusion of blood

There is a bond that links all men and women in the world so closely and intimately that every difference of colour, religious belief and cultural heritage is insignificant beside it. Never varying in temperature more than five or six degrees, composed of 55 per cent water, the life stream of blood that runs in the veins of every member of the human race proves that the family of man is a reality.

Thousands of years ago man discovered that this fluid was vital to him and precious beyond price. The history of every people assigns to blood a unique importance. Folklore, religion and the history of dreams of perpetual youthfulness – of rejuvenation through ‘new blood’ – are filled with examples.

The ‘blood is the life’ says Deuteronomy (xii, 23). ‘For this is my blood of the New Testament which is shed for you’ (Matthew xxvi, 28). Ancient Egyptians were said to bath in blood to refresh their powers and to anoint heads with oil and blood to treat greying and baldness. Ovid describes how Aeson recovered his youthfulness after drinking the blood of his son, Jason. The Romans were said to have drunk the blood of dying gladiators to imbue them with courage. More recently, it has been alleged that certain tribes of Central Australia give to sick old men the blood of young men to drink. Kublai Khan, expressing a widespread belief that the soul is in the blood, refused to allow the spilling of royal blood. Throughout South America the most popular method of driving out a bad spirit was by venesection in the belief that the demons escaped with the blood. Blood brother ceremonies in various countries of the world still fulfil functions of reconciliation and other social purposes while blood feuds – blood being repaid with blood – represented a powerful institution in medieval Europe and form part of conventions in some societies today.

For centuries then in all cultures and societies, blood has been regarded as a vital, and often magical, life-sustaining fluid, marking all important events in life, marriage, birth, initiation and death, and its loss has been associated with disgrace, disgust, impotence, sickness and tragedy. Symbolically and functionally, blood is deeply embedded in religious doctrine; in the psychology of human relationships; and in theories and concepts of race, kinship, ancestor worship and the family. From time immemorial, it has symbolised qualities of fortitude, vigour, nobility, purity and fertility. Men have been terrified by the sight of blood; they have killed each other for it; believed it could work miracles; and have preferred death rather than receive it from a member of a different ethnic group.

The very thought of blood, individual blood, touches the deepest feelings in man about life and death. Attitudes to it and the values associated with its possession, inheritance, use and loss among men and women have been studied by anthropologists as one of the distinctive features of different cultures. Even in modern times, mystical and irrational group attitudes to blood have sharply distinguished certain Western societies – as in Hitler’s Germany with its myths of ‘Aryan’ and ‘Jewish’ blood. Nor can we pursue such thoughts far without being reminded of the contemporary worldwide phenomenon of racial prejudice and its association with concepts of blood impurities, ‘good’ blood and ‘bad’ blood, untouchability and contamination.

Beliefs and attitudes concerning blood affect in varying degrees throughout the world the work of transfusion services in appealing for and recruiting blood donors. A deeply rooted and widely held superstition is that the blood contained in the body is an inviolable property and to take it away is sacrilege. In parts of Africa, for example, and particularly among the Bantu in South Africa, it is believed also that blood taken away cannot be reconstituted and that the individual will therefore be weakened, be made impotent, or be blinded for life; that the white man takes blood to ensure his domination over the black man; and that the needle piercing the skin is an act of aggression which results in the propagation of disease and sickness. We shall have more to say about such beliefs in later chapters when we discuss some of the problems of donor motivation and recruitment.1

The growth of scientific knowledge about the circulation of the blood, the composition and preservation of blood, and the distribution of blood group genes throughout the human race has provided us with a more rational framework. But it is only more recently that scientific advances have made a blood transfusion service an indispensable and increasingly vital part of modern medicine.

Blood, in one form or another, appears in the earliest pharmacopeias. It was a favourite remedy centuries ago for lunacy and palsy and was prescribed for the rejuvenation of the old. The direct transfusion of blood into the circulation had, however, to await the discovery in 1616 that there was a circulation. As news of Harvey’s work spread in Europe, there followed a wave of transfusion experiments. The first recorded attempt to transfuse blood from one body to another was made in 1665 at the suggestion of ‘the busiest of men’, Sir Christopher Wren.2 Dr Richard Lower, the British anatomist, successfully transferred blood from one dog to another. Speculation naturally ensued, much of it centring around the commonly held view at that time that blood carried in it the secrets of individuality. Boyle, in writing to Lower, wondered ‘whether the blood of a mastiff, being frequently transferred into a bloodhound, or a spaniel, will not prejudice them in point of scent’.3 Samuel Pepys was even more imaginative: ‘This did give occasion to many pretty wishes, as of the blood of a Quaker to be let into an Archbishop, and such like’.4

Two years after Lower’s experiments, a French doctor, philosopher and astronomist, Jean Baptiste Denis, performed the first recorded blood transfusion on a human, the patient being a boy of 15 and the blood used being taken from a lamb. This experiment ended in disaster and charges of murder were preferred against the doctor. The practice of transfusing human beings with the blood of animals was, however, taken up in many countries but so many deaths were caused that it was made illegal in France, England and Italy, and in 1678 the Pope forbade it.5

Galen, the doctor of Marcus Aurelius, who was the first man to prove that arteries contained blood and not air, propagated the mistaken idea that blood passed from one side of the heart to the other by ‘sweating’. This mistake lasted for centuries as did his enthusiasm for blood-letting. The trickles of purged blood in ancient Rome had become rivers by the eighteenth century when many surgeons, and even psychiatrists, reduced their therapy to the maxim ‘purge and bleed’. This practice was only abandoned in the twentieth century.

As so often happens with scientific discoveries, little or no progress in the applied field of blood transfusion was made for a long time. One hundred and fifty years after Lower’s experiments, Dr James Blundell, working at St Thomas’s and Guy’s Hospitals in London, invented an apparatus for directly transfusing blood and suggested that only human blood should be used for human beings. In 1818 he gave the first human-to-human transfusion. But the general use of transfusion apparatus had to await the brilliant work of a young Viennese scientist, Karl Landsteiner, who discovered in 1901 that there were different kinds of human blood and that the clumping together (agglutination) of red cells and their consequent destruction occurred if the wrong kinds of blood were mixed. It was finally determined that there were four main human blood groups, now called A, B, AB, and O, according to the presence or absence on the red cells of two chemical substances known as ‘A’ and ‘B’. Safe transfusion, with the intermixing of the blood of two persons without the occurrence of clumping, was discovered to be possible if the patient received blood from a donor of the same blood group.

Turning to more recent history, it was in the 1930s that the Rhesus blood system was first described, soon becoming recognised as an important factor in blood transfusion and one causing problems of incompatibility in pregnancy. By 1941, it had become clear that an antibody described as ‘anti-Rhesus’ (so called after the type of monkey used in the experimental work) was differentially distributed among humans. About 82-3 per cent of the Caucasian population are Rhesus-positive and the remainder are Rhesus-negative.

There is, in fact, a group of Rhesus characters, but the one that gives rise to the most problems is known as ‘Rhesus D’. When an individual who is Rhesus D negative is transfused with Rhesus D positive cells, antibodies may be made which attack and destroy transfused blood. A similar situati...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• Editorial Preface
• New Introduction
• List of tables
• Preface
• 1: Introduction: human blood and social policy
• 2: The transfusion of blood
• 3: The demand for blood in England and Wales and the United States
• 4: The supply of blood in England and Wales and the United States
• 5: The gift
• 6: The characteristics of blood donors in the United States
• 7: The characteristics of blood donors in England and Wales
• 8: Is the gift a good one?
• 9: Blood and the law of the marketplace
• 10: Blood donors in the Soviet Union and other countries
• 11: A study of blood donor motivation in South Africa
• 12: Economic man: social man
• 13: Who is my stranger?
• 14: The right to give
• Appendix 1: Notes on blood and blood transfusion services in England and Wales1
• Appendix 2: Notes on the use of blood in the United States and England and Wales in 1956
• Appendix 3: Regional statistics for England and Wales, 1951-65
• Appendix 4: The Donor Survey: The characteristics of Donors
• Appendix 5: Donor survey questionnaire
• Appendix 6: Analysis of blood donor motives
• Appendix 7: Acknowledgements
• Endnotes
• Bibliography